Ask Dr. Z

I am unsure what CPT to use for the catheter placement in the central shunt. A congenital heart cath was performed, and a pigtail cath was placed within the central shunt with findings listed of the SVC, bilateral innominate veins, and bilateral pulmonary arteries. What code would I use for the cath placement in the central shunt? 

Surgeon performs wedge resection on lung mass. Frozen section shows consistent with nonsmall cell carcinoma, and a lobectomy is performed in the same setting. One month later, patient is planned for chemo and port-a-cath has been requested for chemo access. Same surgeon places port-a-cath. Two weeks later, total decortication is performed on contralateral lung (in relation to lung mass resection) for pleural effusion. Which modifiers are correct for these situations? 58? 78? 79? Is the Port-a-cath related to the resection since the cancer was found during that service (use of 78 modifier)? Is the contralateral decortication unrelated because it is contralateral (use of 79 modifier)?

We have a patient who has ventricular intracranial shunt displacement. Neurosurgery administered In-111 DTPA and our radiologist is interpreting images. In 2015 (Question ID: 6377) you recommended 75809. Would that still be your recommendation today? Would we bill 75809 with -52 mod if we interpreted images but did not supervise, or would we bill individual xrays? Report states: "EXAM: NM CSF SHUNT EVALUATION HISTORY: Ventricular intracranial shunt displacement TECHNIQUE: 1.1 mCi of In-111 DTPA was administered into the patient's right sided shunt reservoir by neurosurgery. Subsequent imaging of the head, neck, chest, abdomen, and pelvis were performed immediately after the radiopharmaceutical administration and at 4 hours. FINDINGS: Initial activity in the shunt reservoir and ventricles is identified. On immediate images, there is faint activity noted along the course of the shunt catheter with activity noted in the perioneal cavity and no evidence of localized collections. IMPRESSION: Findings consistent with patent ventriculo-peritoneal shunt."

"The fibrous ingrowth cuff of the indwelling tunneled dialysis catheter was freed by blunt dissection. A wire was advanced into the venous system, and the catheter was retracted. Multiple digital subtraction images were obtained, showing the presence of a fibrin sheath. The catheter was then removed, and a Fogarty catheter was advanced over wire and a Fogarty technique utilized for fibrin sheath maceration. A new hemodialysis catheter was then exchanged over wire through the existing tunnel with tip overlying the level of the cavoatrial junction. The wire was removed, and the catheter was secured with suture, flushed, and working well." Would unlisted code 37799 or codes 36595-52 and 75901 be used?

Regarding the use of codes 37241 and 36005 for venous malformation. "PRE-EMBOLIZATION ANGIOGRAM #1: Direct puncture in the posterior left leg is performed with a 23 gauge needle. Access in the malformation is accomplished. Contrast is injected an angiogram is performed and the study is reviewed to determine treatment of that malformation compartment percutaneously accessed. (The above is repeated sometimes up to 8 times – each puncture into the same part of the leg, pre and post angiograms are being performed, with 36005 reported for each pre-embolization angiogram.) After injecting 4 mL of ethanol contrast is injected an angiogram is performed the study is reviewed and thrombosis of this compartment is now noted." Also, if the malformation is found in the chest area, utilizing direct puncture, is there a more appropriate code to use other than 36005, or is 37241 the only code reportable? The provider is reporting the codes as noted above. We feel code 36005 is not appropriate to report for the cases and would appreciate your expertise.

"Patient brought to the cath lab where selective angiography of the right and left coronary arteries was performed. Then the catheter was withdrawn into the aortic arch and engaged the left subclavian artery. Angiography of the left subclavian and indirect angiography of the left internal mammary artery in situ was performed without apparent complication. Catheter was then exchanged over the J wire for a 6 French pigtail catheter. This catheter was advanced over the J wire across the aortic valve and placed in the left ventricular chamber. Indwelling pressure of the left ventricular chamber was obtained followed by performance of left ventriculopathy with the administration of 40 ml of contrast at a rate of 15 ml/second by power injection. This then concluded the procedure with removal of all catheters from the body." My question is regarding the selective subclavian catheter placement. Is this reportable in addition to the LHC? If so, what CPT should be reported? Provider states patient will be referred for bypass grafting.

My physician removed a SC ICD on the right and capped the RV lead and closed the incision. A new SC ICD on the left was placed with new RV lead. Coding 33249, 33241, 33223?

How would you code this op? Physicians want 37221-RT, 34705, 35371-50, 35372-RT, and 34812x2. “Incision over femorals, dissected out CFA, SFA, & PFA. On LT, needle access of CFA but wire wouldn’t pass dense calcific disease. Proceed w/endarterectomy on LT. Incision in CFA & 2 cm into SFA. Plaque taken from CFA, SFA & PFA. Closure began leaving 1 cm gap. 12 Fr sheath placed through gap. On RT, 18 Fr sheath was placed. Main body deployed. Contralateral LT iliac limb deployed through sheath on LT. Extension limbs were needed but not because of continued aneurysmal disease. The main body went down to the iliac bifurcation on the RT with a known occlusion of RT int iliac artery. Elected to extend stent down 5 cm into EXT iliac artery. Iliac stent deployed. Sheath removed. Closure completed. Then endarterectomy on RT. Incision in CFA & several cm into SFA. Endarterectomy done on CFA and proximal PFA but there remained significant disease beyond. Separate arteriotomy is made on PFA for distal endarterectomy. Endarterectomy done in distal PFA. Patch closure on CFA & PFA.”

Does documentation alone of "Deep Hypothermic Circulatory Arrest" enough to imply no cross-clamp and open anastomosis was performed? Is documentation of "hemiarch reconstruction" alone describe how much of the ascending aortic aneursym was resected and where the distal anastomosis was done? I am being told that these statements alone are enough to bill hemiarch +33866 without documenting EACH of the specific CPT guidelines. (1. DHCA 2.incision into the transverse arch under the arch vessels and also 3. extension of the ascending aortic graft to the aortic arch by beveled anastomosis without a cross-clamp.

If a patient has a GJ tube that has become dislodged/pulled out and a Foley catheter or G tube is placed in the stomach to keep the track open, the patient then goes to IR for replacement of the GJ and leaves IR with a new GJ in place. Is this considered a GJ replacement since the patient initially had a GJ tube, or is this a conversion from a G tube to GJ since the tube or catheter was in the stomach at time of replacement? 49452 vs. 49446

Is it correct that 79445 should not be reported during SIRT mapping because the administration of radionuclide is not therapeutic and is included in the nuclear medicine portion of the exam that day? In addition, if during our mapping is it okay to report 76380-XE if diagnostic Spin CT was performed during the IR angiographic study and findings were given? Or is this Spin CT considered part of the same encounter as the nuclear medicine SPECT CT exam 78830?

Ulcers that "looked like saccular aneurysms". Three Gore cuffs used, with 16 French sheath. Not sure what code to use? EVAR codes do not seem to describe. Is this considered a stent (37236) or EVAR? How many can be coded? Three used, help!

Can you please tell me what CPT codes to use for a left VATS and ligation of the left atrial appendage with articlip procedure? Indication is for PAF and inability to anti-coagulate. I'm thinking unlisted code 33999, but I would appreciate your feedback.

What is the professional CPT used to bill AMPLATZER™ PI Muscular VSD device under an HDE? Should we use unlisted code 93799?

What is the appropriate CPT code for functional MRI of liver?

"Diagnosis lung cancer, right lower lobe. Three ports were created in the chest wall. A 5 mm thoracoscope was inserted. The inferior pulmonary ligament was mobilized. An anterior hilar dissection was performed. The right inferior pulmonary vein was isolated and transected with an endoGIA stapler. Next, the bronchus to the lower lobe was isolated in the usual manner and transected. The fissure was completed, and pulmonary arterial branches were taken. The specimen was removed in an endocatch bag. A mediastinal lymph node dissection was performed, taking multiple level 4 and 7 nodes. N1 nodes were taken during the lobectomy as well.  The right upper lobe mass was readily palpated. It was wedged out using an endoGIA stapler. It was relatively small. Chest tubes were placed, and the lung was reinflated. Dressings were applied, and the patient was brought to the ICU in stable condition." Should I use code 32666 or 32608 for RUL?

In order to qualify for 71101 (unilateral ribs including PA chest), does the chest view have to be PA, or can it be stated as frontal, AP, or single-view chest?

When performing an embolization (61624) it is my understanding if the patient has had a previous diagnostic angiogram, then we would report the treatment codes (36126-36218) with the embolization. Is there ever an instance in which diagnostic and treatment codes could be reported together with the embolization? For instance, 61624 for the left MCA, 36217 left MCA, and 36223 for right common carotid, with the rationale that once the coil has been placed a clinical change has occurred in the patient, and therefore a diagnostic code could be reported for the vessels of the side not treated?

How would you code venous arterialization where an artery is anastomosed to a vein through an open approach, distal valve lysis is performed, and distal venous side branches are ligated via separate incision? Are the fistula creation codes only for dialysis, or would it be appropriate for venous arterialization procedures?

Code C9600 is not listed as a primary code in the OCE editor for 92921. Is your recommendation still to use 92921 with C9600?

For real-time visualization of vascular needle entry with permanent recording, does the image have to be a video recording, or can it be just a picture of the needle entering the vessel?

Is 35231 the correct code for the following? "Procedure: 1) RT ext jugular vein harvest measuring 3 cm. 2) Anastomosis of the LT facial artery to the vein graft to the peroneal artery. Bulldog clamp used to achieve hemostasis while the rest of the hematoma was copiously irrigated. The external carotid artery stub was noted to be too short to reach the remaining peroneal artery and the right neck was evaluated for any suitable vein graft candidate. The right external jugular vein was found to be patent and of adequate length. Careful dissection along the superior aspect of the sternocleidomastoid muscle released the external jugular vein from the surrounding tissue. Approximately 2 to 3 cm of vein was harvested and was brought into the left neck. This was cleaned in preparation for microvascular anastomosis. Superior aspect of the external jugular vein was anastomosed in an end-to-end fashion to the left common carotid artery using interrupted 9-0 nylon suture. Distal aspect of the external jugular vein was then anastomosed to the peroneal in an end to end fashion."

Can code 93290 be used to report CardioMEMS recalibration during right heart catheterization?

How would you code for bilateral L1-L4 angiogram? We have billed this as 36245 x 3 (due to MUE) and the remaining as 36245 x 5. Now we have some carriers wanting this billed with modifier -50 (DOS prior to 2020). So would I bill that as 36245 -50 x 4 since I have a total of 8 injections?

Surgeon requested quadratus lumborum and lateral femoral cutaneous blocks for post operative pain management for a hip replacement. Both blocks were single-shot. The quadratus lumborum approaches use a fascial plane through which the abdominal branches of the lumbar arteries course. The lateral femoral cutaneous nerve originates directly from the lumbar plexus and is not a branch of the femoral nerve. Is 64450 the appropriate code?

We are consistently getting denied for CPT code 76377 when performing a diagnostic angiogram or aneurysm embolization procedure. When CPT codes 36221 through 36228 were first introduced in 2013 according to CPT Changes issued by the AMA, code 76377 was an approved reportable code when used during catheterization CPT codes 36221-36228, and it was a necessary and essential component of the endovascular management and of diagnosis complex lesions and management and diagnosis of cerebral aneurysms. We recently noticed that Medicare is no longer paying for 76377 when we code the usual ICD-10 codes, which we had in the past year for justification of these procedures. We also noticed when searching that there are no longer ICD-10 codes matched for 76377 that begin with an "I" besides I05.0-I05.9, I08.0-I08.9, I23.1-I23.5, I33.0, I34.0-I34.9, I36.1-I36.9, I39, I48.0, I48.11-I48.21, I48.3-I48.4, I48.91-I48.92, I51.0-I51.2, I97.110-I97.19. None of these codes can be used for our procedures. What is the reason for the reduction of ICD-10 codes and what can we do?

2019 instructions were clear, nothing for less than 10 minutes, then 10-22 minutes, then each additional 15 minutes or fraction thereof. I'm not so clear on the 2020 rules. Code 99152 is for the first 15 minutes. Is that to say 99152 can be used for 1 to 15 minutes? So if the monitoring is 7 minutes it would be appropriate to report 99152?

Is code 36907 reportable for “cephalo-subclavian junction” stenosis? "AVF aneurysm: The left arm was isolated as a sterile field. After Marcaine Xylocaine infiltration the arterial side of the fistula was incised to dissect out the aneurysm and overlying thin skin with appropriate in flow and outflow vessel. There was enough redundancy in the fistula that the aneurysm could be resected with end to end closure of the inflow and outflow vein. 5000 units of heparin was given and the fistula was clamped proximally and distally. The aneurysm was resected. The marks needle was inserted into the cut venous side of the fistula. A central venogram was obtained. Outflow veins were followed into the atrium and there was evidence of 70% narrowing of the lumen at the level of the proximal stent of the cephalo-subclavian junction. A 7 french introducer was placed and a 10 mm 4 cm charger balloon dilatation catheter was passed and the lesion was dilated to profile. The two ends were sutured end to end with 4-0 prolene. When clamps were released there was a good thrill in the fistula and a hemostatic anastomosis."

"Patient is status post Pipeline embolization. Patient clinicially, CTA and TCDs are consistent with vasospasm. Right vertebral angiogram showed vasospasm. Vasospasm was treated with 10 mg of intra-arterial verapamil over a 10-minute infusion. Left internal carotid angiogram showed vasospasm and filling of the left ophthalmaic aneurysm. The vasopasm was treated with 10 mg of intra-arterial verapamil over a 10-minute infusion. Given persistent filling of the aneursym, an additional Pipeline embolization was performed. A 4 x 12 Pipeline was successfully deployed. Two follow-up angiograms of the left internal carotid were performed." Can we charge for follow-up angiograms with a modifier for the embolization? Follow-ups are bundled with codes 61650 and 61651.

Would the appropriate code for this procedure be 36468-50? Should we code 36470-50 in addition for the reticular veins? "Procedure: The patient was prepped and draped in the usual fashion. Utilizing ultrasound as well as vein light, access was obtained into abnormal appearing venous structures. Polidocanol solution was instilled at each of these locations. Follow-up ultrasound at the conclusion was performed. Findings: Use of ultrasound and vein light systems allowed for access of reticular veins and telangiectasias. These sites were accessed, and polidocanol solution was instilled. There were no significant residual sites present bilaterally at the conclusion. Impression: Successful sclerotherapy performed bilaterally."

We're having a disagreement. Is the mention of a Hickman or Trifusion cath removal with blunt dissection of cuff enough to charge tunneled cath removal 36589? I am being told it must say "tunneled", and while I agree that would be great if it did, I am thinking that if you use blunt dissection to release the cuff, it has to have been tunneled. The order to remove stated "removal of tunneled Hickman catheter" by the way.

Code 37197 is for percutaneous removal of foreign body. What code do we use for open procedures? Patient had a stent due to aneurysm and the stent thrombosed. Removed stent and did a bypass.

"Left fem-peroneal bypass using reversed ipsilateral greater saphenous vein. After patching the femoral artery with a portion of the greater saphenous vein the vein was then anastomosed and tunneled to the level of the peroneal artery. It was diseased in the more proximal segment, so a patch was placed with a segment of the GSV, and then the graft was anastomosed end-to-side into the patch. Angiography confirmed poor outflow fromt he peroneal segment. Provider then harvested a segment of the contralateral GSV and created an end-to-side anastomosis within the prior bypass and an end-to-side anastomosis between the jump graft and peroneal artery." We feel that code 35566 is supported for the initial bypass graft. We are not sure about the jump graft in this case. Is there a separately reportable code option for this additional work?

Our surgeon routinely performs a common femoral through profunda and SFA endarterectomy (35371). A couple of questions regarding inflow/outflow and follow-up angiography. More often than not he will do a post endarterectomy angiogram with a contralateral stick (over the horn) approach with findings. Is this billable or considered bundled? Subsequently he will stent the external iliac into the common femoral (37221). This appears to be billable, as it’s considered a different vessel from the CF endarterectomy... is that correct? He then proceeds to stent the proximal SFA and profunda femoral origin. Now would this be considered bundled, as it’s included in the inflow/outflow coding rules? These can be confusing on what is actually codable and what is bundled. My codes are: 35371 and 37221 with the rest considered bundled. What is your opinion on this?

I have surgeons who want to use modifier -22 on codes 33405 and 33406 because they document a minimally invasive approach. At the STS 2020 Conference, they stated that these codes include the approach (open, minimally invasive, or robotic) and no modifier should be used. What is your recommendation on the use of modifier -22 for minimally invasive procedures? Example: -22 modifier for non-sternotomy case. "Right mini anterior thoracotomy incision was made over the 3rd rib. This incision was taken down to the 3rd rib. The right internal mammary artery and vein were identified and clipped and transected. A segment of cartilage was then removed, and the Alexis soft tissue retractor was then inserted to expose the upper mediastinum. Pericardial fat was excised and pericardium was opened and pericardial stitches were placed to expose the aorta."

Cardiologist exchanges the ICD generator due to end of life (single chamber RV) and also puts in new lead due to lead failure. The documentation states, "New lead was placed in the right ventricular septum and sutured. The yoke of the old lead was cut and removed, and the residual portion of the old lead was capped." I am thinking this should be reported with codes 33249 and 33241, but another coder says it is 33262 and 33244. Please explain how you would code this and what does it mean when they say, "Yoke of old lead was cut and removed but also capped"? Is this a removal or a capping of lead?

If the physician performed a right heart cath, and then attempted a transseptal puncture but was unable to cross the atrial septum (after multiple attempts for more than one hour), can I report code 93532-52, or would I just report code 93530?

"Two-week-old infant with Tetralogy of Fallot with severe outflow tract obstruction and threatened discontinuity of pulmonaries. He is status post modified right Blalock Taussig shunt and pumonary artery arterioplasty. A pigtail catheter is inserted in the right femoral artery, advanced retrograde into the ascending aorta, and LHC performed. Selective cath was used for innominate angiography with findings of complete occlusion of BT shunt. Tyshak II angio cath was advanced across the shunt. Three inflations were performed to 6 ATM. Terumo catheter was advanced into pulmonary artery for pulmonary pressures. Selective angio of transverse aorta with findings; selective angio of pulmonary arteries, innominate artery, Blalock shunt all with findings. Successful angioplasty of BTS." For coding, I think 93452 for congenital LHC, 93568 for pulmonary angiography, and 37246 for BTS angioplasty, but I'm unsure about the codes for the transverse aortic and innominate artery angiography. I would appreciate your thoughts on this.

Many of our dialysis patients have angioplasties or thrombectomies or stents performed in AVF/AVG. These procedures fall in the global period of the same AVF/AVG placement or revision. What modifier should be used for the physician charges for the procedure performed in the global period? The fistula repair is usually related to the patient's underlying illness (renal disease) not directly related to the fistula's creation or revision and is not strictly a complication of the earlier procedure. 

For this OP report, would you report codes 35371 and 35302 for both sides? "Attention is then turned to the right femoral artery. An arteriotomy is made with 11 blade and extended with Potts scissors in the CFA and carried down onto the first 2-3 cm of the SFA. An endarterectomy was then performed. The Penfield elevator was used to create a plane. The proximal endpoint was cut flush with tenotomy scissors, and proximal plaque was then removed with a hemostat. This was in the proximal CFA. An eversion endarterectomy was then performed for the first 2 cm of the PFA with a nice feathered endpoint seen. The distal endpoint of the SFA endarterectomy was created with gentle traction, and the distal endpoint was not initially clear of plaque. The plaque down the SFA on the right was fairly extensive, and we extended our arteriotomy another couple of centimeters down the SFA to be able to get a nice feathered distal endpoint, which we were able to achieve. The same was done on the left except there was a stent in the SFA that they had to partially transect."

Patient comes in for an ICD implant. They extubate the patient, and patient becomes violent and dislodges a lead. Patient consents to immediate lead revision. Patient is then re-prepped, placed back under anesthesia, and they fix the dislodged lead. They never left the OR. Do we capture the lead revision, or is it included in the initial implant since they did not leave the OR?

We have a patient who had an above-knee amputation (27590) one month ago, but then came back due to infection and had a revision, although they are doing a guillotine type revision being left open at the end of the case. The patient went back to the operating room five days later and had another revision with more bone, but this time it was closed. Would we code both revisions as 27596-78, or the first revision as 27592 and second revision as 27596?

Would 50435 be used for following? "Patient has existing nephrostomy tube for two weeks, but now has leaking. OR procedure: Patient in the prone position. The nephrostomy was to release the suture that is holding the nephrostomy in the loop in the renal pelvis. The nephrostomy was then intubated using a 0.35 Glidewire. The nephrostomy was removed. Using the nephrostomy dilator we then maneuvered the Glidewire so that it would go all the way down to the ureter into the bladder. At this point then we were able to dilate the nephrostomy tract to 14 French. After dilating the nephrostomy tract an 14 French were then introduced the 12 French nephrostomy tube together with its obturator through the Glidewire and then maneuvered the nephrostomy so that the loop will be made right at the renal pelvis. Having looked into the renal pelvis then the procedure was basically terminated the the suture was locked that holds the loop of the nephrostomy."

How would you recommend coding this? "The pocket was opened, and a new azygos vein lead was placed due to failed ICD therapy. The old generator was then removed and replaced with a new high energy generator, which was attached to the previously placed RV lead and the new azygos lead."

Patient presented for a right heart cath for LVAD workup. "We then attempted to advance a Swan-Ganz catheter into the RA; however, it would not pass the mid portion of the subclavian vein due to likely stenosis from multiple pacing wires. We then advanced a Grandslam wire into the RA and performed venoplasty using a 2.0 x 25 mm balloon. However, the Swan would still not pass. We then advanced a 5 French MP through the stenotic segment using balloon-assisted tracking. Through the 5 French MP catheter we then advanced a wedge catheter into the PA, which was then used to perform right heart catheterization." The rest of the right heart cath with angiography went fine and was documented appropriately. Can I submit code 37248 for the venoplasty performed in addition to 93456? Or is there a better code?

"Access site was right posterior tibial vein. Venography was performed at right posterior tibial vein, popliteal vein, femoral vein, common femoral vein, right iliac vein, and IVC. Venography demonstrated total occlusion of femoral, popliteal, and right posterior tibial vein. From same access site, venoplasty was performed at right posterior tibial vein, popliteal vein, and femoral vein using different venoplasty balloons." Should it be coded with 34248 and 37249 x 2 for venoplasties done at three levels, 36012 for catheter placement only as all lesser vein are in route to IVC, 75825 for IVC venography, and 75820 for extremity venography? I'm confused how to exactly code this scenario because there is very limited info regarding venous studies and interventions and also code set variate as compared to arterial system.

Can we report code 49185 even though imaging guidance wasn't performed, and contrast wasn't administered? Can we also report code 49185 when sclerosants aren't used? "Provider injected 30 mL of desiccated ethanol into the abdominal wall seroma via previously placed drain. Patient was turned every 15 minutes to allow the alcohol to bathe all sides of the seroma cavity. The alcohol was then aspirated completely with 30 mL removed. Patient tolerated procedure well."

We are debating whether this would be a stent or a catheter replacement. One of us has coded 50382, and someone else coded 50387. "Small amount of contrast was injected through the left pre-existing NUS, confirming appropriate location and occlusion of the distal aspect of the tube. The catheter was transected and removed over wire. The wire could not be passed into the distal pigtail and submitted a proximal side hole. A Balkan sheath was advanced over the wire and used to advance a wire across the occluded ureter. This was ultimately successful in recovery of the pathway into the bladder. Over wire, the system was exchanged for a new 8.5 French 40 cm biliary catheter used as NUS. Catheter tip pigtailed in the bladder." Is there a good way to tell the difference between a stent and catheter? Our physicians use the words interchangeably, sometimes even in the same OP note.

If a patient has a right heart cath and is found to be in cardiogenic shock and admitted to transplant ICU for Swan-directed therapy, does that qualify for billing 93561/93562, and what type of documentation shall I look for? I know you would bill 93561 the first day after the cath and 93562 each subsequent day until removed.

Physician performed aspiration on two renal cysts under ultrasound guidance. Can we code each cyst separately with 50390 with US once?